Deficiency Records for Crown Bay Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Crown Bay Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-08-10 | 2023-10-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-02 | 2023-08-28 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-05-11 | 2022-06-06 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-09 | 2022-06-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-10 | 2022-01-25 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-12-10 | 2022-01-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-08 | 2021-11-23 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-07 | 2020-01-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-22 | 2019-12-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-11-22 | 2019-12-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-11-22 | 2019-12-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-22 | 2019-12-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-22 | 2019-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-22 | 2019-12-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-11-22 | 2019-12-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-22 | 2019-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-22 | 2019-12-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-22 | 2019-12-22 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-11-22 | 2019-12-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-22 | 2019-12-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-22 | 2019-12-22 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-11-22 | 2019-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-22 | 2019-12-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-22 | 2019-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-14 | 2019-01-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-14 | 2019-01-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-14 | 2019-01-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-14 | 2019-01-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-14 | 2019-01-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-14 | 2019-01-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-10-11 | 2018-11-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-10-11 | 2018-11-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-11 | 2018-11-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-11 | 2018-11-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-11 | 2018-11-11 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-11 | 2018-11-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-11 | 2018-11-11 | N |
| Provide appropriate foot care. | Health | 2018-10-11 | 2018-11-11 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-10-11 | 2018-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-11 | 2018-11-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-11 | 2018-11-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Develop a communication plan. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-12-27 | 2018-01-22 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-11-22 | 2017-12-21 | N |
| Provide timely notification to the resident before transfer or discharge. | Health | 2017-11-22 | 2017-12-21 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-11-22 | 2017-12-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-11-22 | 2017-12-21 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-11-22 | 2017-12-21 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-22 | 2017-12-21 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-11-22 | 2017-12-21 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-11-22 | 2017-12-21 | N |
